Guidance on Hospice Care and Feeding Tubes for Elderly Patients

Palliative Care KSA

Megan Matott, DO, Hospice and Palliative Medicine Fellow, Rochester Regional

Health 

Greg Faughnan, MD, Faculty, St. Joseph's Family Medicine Residency

A 74-year-old female has been hospitalized three times in the past 6

months for exacerbations of heart failure with preserved ejection

fraction. During rounds the family medicine resident on the team asks

whether a hospice referral would be appropriate.

Which one of the following is true about hospice care for this patient?

A.

Hospice would focus on helping her live well

B.

She does not qualify for hospice because her ejection fraction is preserved

C.

Hospice is inappropriate for noncancer diagnoses

D.

Patients under hospice care die earlier because they lose the will to live

A 74-year-old female has been hospitalized three times in the past 6

months for exacerbations of heart failure with preserved ejection

fraction. During rounds the family medicine resident on the team asks

whether a hospice referral would be appropriate.

Which one of the following is true about hospice care for this patient?

A.

Hospice would focus on helping her live well

B.

She does not qualify for hospice because her ejection fraction is preserved

C.

Hospice is inappropriate for noncancer diagnoses

D.

Patients under hospice care die earlier because they lose the will to live

An 89-year-old female with advanced Alzheimer’s dementia has resided in a skilled

nursing facility for the past 5 years. She will eat if she is hand fed but has been

hospitalized three times in the past 4 months for aspiration pneumonia. The family asks

about tube feedings.

Which one of the following would be appropriate advice for this patient’s family?

A.

The risk of aspiration is reduced with a feeding tube

B.

The quality of life for patients with advanced dementia is so low that a feeding

tube is inappropriate

C.

Feeding tubes increase longevity in patients with advanced dementia

D.

Feeding tubes prevent pressure ulcers in patients with advanced dementia

E.

Careful hand feeding has been shown to be as effective as tube feeding

An 89-year-old female with advanced Alzheimer’s dementia has resided in a skilled

nursing facility for the past 5 years. She will eat if she is hand fed but has been

hospitalized three times in the past 4 months for aspiration pneumonia. The family asks

about tube feedings.

Which one of the following would be appropriate advice for this patient’s family?

A.

The risk of aspiration is reduced with a feeding tube

B.

The quality of life for patients with advanced dementia is so low that a feeding

tube is inappropriate

C.

Feeding tubes increase longevity in patients with advanced dementia

D.

Feeding tubes prevent pressure ulcers in patients with advanced dementia

E.

Careful hand feeding has been shown to be as effective as tube feeding

A 51-year-old male with squamous cell cancer of the mouth is considering

chemotherapy and radiation therapy. He has seen some information indicating that a

feeding tube is sometimes used during this treatment and he asks you for information

about this.

Which one of the following would be appropriate advice?

A.

A nasogastric feeding tube is recommended to minimize the need for surgery

B.

A percutaneous endoscopic gastrostomy (PEG) tube is a better option than a

nasogastric tube

C.

Total parenteral nutrition would be the preferred route to provide nutrition for

this patient

D.

A feeding tube has not been shown to improve symptoms or longevity in patients

with head and neck cancer

A 51-year-old male with squamous cell cancer of the mouth is considering

chemotherapy and radiation therapy. He has seen some information indicating that a

feeding tube is sometimes used during this treatment and he asks you for information

about this.

Which one of the following would be appropriate advice?

A.

A nasogastric feeding tube is recommended to minimize the need for surgery

B.

A percutaneous endoscopic gastrostomy (PEG) tube is a better option than a

nasogastric tube

C.

Total parenteral nutrition would be the preferred route to provide nutrition for

this patient

D.

A feeding tube has not been shown to improve symptoms or longevity in patients

with head and neck cancer

Although prognostication is often difficult, it promotes thoughtful

decision-making, allows for planning, and is often appreciated by

patients and families. Which one of the following is true about

determining a prognosis?

A.

A prognosis should be given as a range of time

B.

Physicians tend to underestimate longevity

C.

The accuracy of a prognosis improves the longer a physician has

known a patient

D.

Multidisciplinary teams are less accurate than individual physicians

when determining a prognosis

Although prognostication is often difficult, it promotes thoughtful

decision-making, allows for planning, and is often appreciated by

patients and families. Which one of the following is true about

determining a prognosis?

A.

A prognosis should be given as a range of time

B.

Physicians tend to underestimate longevity

C.

The accuracy of a prognosis improves the longer a physician has

known a patient

D.

Multidisciplinary teams are less accurate than individual physicians

when determining a prognosis

A 79-year-old female with Alzheimer’s dementia responds to familiar faces and can

speak in short sentences. Until recently she has been able to feed herself but she now

requires help with eating and other activities of daily living. She is occasionally

incontinent of urine and has been hospitalized twice in 3 months for a urinary tract

infection (UTI) with fever. Since her last hospitalization for a UTI she has become

unable to walk and requires a one-person assist to get into a wheelchair. A home

health nurse sees her three times a week to manage pressure sores.

Which one of the following is true regarding this patient’s qualification for Medicare

hospice?

A.

She does qualify because the natural course of advanced dementia usually leads

to death in less than 6 months

B.

She does qualify because the comorbidity of frequent hospitalization suggests a

prognosis of less than 6 months

C.

She does not qualify because she can speak more than six words

D.

She does not qualify because she can respond to familiar faces

A 79-year-old female with Alzheimer’s dementia responds to familiar faces and can

speak in short sentences. Until recently she has been able to feed herself but she now

requires help with eating and other activities of daily living. She is occasionally

incontinent of urine and has been hospitalized twice in 3 months for a urinary tract

infection (UTI) with fever. Since her last hospitalization for a UTI she has become

unable to walk and requires a one-person assist to get into a wheelchair. A home

health nurse sees her three times a week to manage pressure sores.

Which one of the following is true regarding this patient’s qualification for Medicare

hospice?

A.

She does qualify because the natural course of advanced dementia usually leads

to death in less than 6 months

B.

She does qualify because the comorbidity of frequent hospitalization

suggests a prognosis of less than 6 months

C.

She does not qualify because she can speak more than six words

D.

She does not qualify because she can respond to familiar faces

A 65-year-old male with metastatic pancreatic cancer is admitted to

the hospital for management of a pain crisis. While he is hospitalized

his opioid medications are titrated to control his pain. On hospital day

10, after a goals-of-care conversation with his hospital team, he

decides to change to comfort-focused treatment.

Which one of the following would be most appropriate for this patient?

A.

Docusate sodium (Colace), 1 tablet orally daily as needed for constipation

B.

Senna, 2 tablets orally at bedtime daily for constipation

C.

Psyllium (Metamucil), 1 capful daily with 8 ounces of water for constipation

D.

Diazepam (Valium), 5 mg orally every 1 hour as needed to control agitation

A 65-year-old male with metastatic pancreatic cancer is admitted to

the hospital for management of a pain crisis. While he is hospitalized

his opioid medications are titrated to control his pain. On hospital day

10, after a goals-of-care conversation with his hospital team, he

decides to change to comfort-focused treatment.

Which one of the following would be most appropriate for this patient?

A.

Docusate sodium (Colace), 1 tablet orally daily as needed for constipation

B.

Senna, 2 tablets orally at bedtime daily for constipation

C.

Psyllium (Metamucil), 1 capful daily with 8 ounces of water for constipation

D.

Diazepam (Valium), 5 mg orally every 1 hour as needed to control agitation

A 72-year-old female has recently been diagnosed with advanced

idiopathic interstitial pulmonary fibrosis. You explain the diagnosis and

prognosis and advise her on breathing exercises.

Which one of the following would be most likely to decrease her sense

of breathlessness and improve her exertional tolerance without

affecting mortality?

A.

As-needed morphine

B.

Scheduled morphine

C.

As-needed lorazepam

D.

Scheduled lorazepam

A 72-year-old female has recently been diagnosed with advanced

idiopathic interstitial pulmonary fibrosis. You explain the diagnosis and

prognosis and advise her on breathing exercises.

Which one of the following would be most likely to decrease her sense

of breathlessness and improve her exertional tolerance without

affecting mortality?

A.

As-needed morphine

B.

Scheduled morphine

C.

As-needed lorazepam

D.

Scheduled lorazepam

A 52-year-old female Hmong patient is hospitalized with acute

gastrointestinal bleeding, presumably associated with her known colon

cancer. Her husband explains that people of their culture believe that

spirits are responsible for illness. The patient believes that she brought

on her illness by traveling close to a large body of water where the

spirits live.

Which one of the following would be an appropriate response?

A.

The bleeding is from your cancer

B.

The idea of spirits causing your bleeding is unfounded and you

should not feel guilty

C.

I’m going to ask my partner from behavioral health to see you

D.

What else should I know about your culture?

A 52-year-old female Hmong patient is hospitalized with acute

gastrointestinal bleeding, presumably associated with her known colon

cancer. Her husband explains that people of their culture believe that

spirits are responsible for illness. The patient believes that she brought

on her illness by traveling close to a large body of water where the

spirits live.

Which one of the following would be an appropriate response?

A.

The bleeding is from your cancer

B.

The idea of spirits causing your bleeding is unfounded and you

should not feel guilty

C.

I’m going to ask my partner from behavioral health to see you

D.

What else should I know about your culture?

The table below displays the conversion factors for morphine, hydrocodone,

hydromorphone, and oxycodone. Based on this chart, which one of the following

statements is accurate?

A.

A 2-mg dose of oral hydromorphone is roughly equivalent to 5 mg of oral oxycodone

B.

A 5-mg dose of oral oxycodone is roughly equivalent to 15 mg of oral morphine

C.

A 45-mg dose of oral hydrocodone is roughly equivalent to 4 mg of oral hydromorphone

D.

A 2-mg dose of intravenous morphine is roughly equivalent to 0.1 mg of intravenous

hydromorphone

The table below displays the conversion factors for morphine, hydrocodone,

hydromorphone, and oxycodone. Based on this chart, which one of the following

statements is accurate?

A.

A 2-mg dose of oral hydromorphone is roughly equivalent to 5 mg of oral

oxycodone

B.

A 5-mg dose of oral oxycodone is roughly equivalent to 15 mg of oral morphine

C.

A 45-mg dose of oral hydrocodone is roughly equivalent to 4 mg of oral hydromorphone

D.

A 2-mg dose of intravenous morphine is roughly equivalent to 0.1 mg of intravenous

hydromorphone

Using the chart provided it is possible to calculate equivalent dosages for opioids. A 20-

mg dose of oral oxycodone is equivalent to 30 mg of oral morphine, so multiplying the

oxycodone dose by 1.5 will provide the equivalent dose of morphine. A 5-mg dose of

oral oxycodone is therefore equivalent to 7.5 mg of oral morphine.

A 57-year-old female with stage IV ovarian cancer presents to the

emergency department with a new onset of shortness of breath. She is

unable to lie down or complete sentences. A chest radiograph reveals a new

large, likely malignant, pleural effusion.

Which one of the following is true about this condition?

A.

Repeated thoracentesis is contraindicated because it increases the

mortality risk

B.

Tunneled pleural catheters are expensive and ineffective for managing

this problem

C.

Chest tube drainage alone prevents re-accumulation of fluid at 30 days

60%–80% of the time

D.

Systemic chemotherapy or hormonal therapy is the most effective

treatment

A 57-year-old female with stage IV ovarian cancer presents to the

emergency department with a new onset of shortness of breath. She is

unable to lie down or complete sentences. A chest radiograph reveals a new

large, likely malignant, pleural effusion.

Which one of the following is true about this condition?

A.

Repeated thoracentesis is contraindicated because it increases the

mortality risk

B.

Tunneled pleural catheters are expensive and ineffective for managing

this problem

C.

Chest tube drainage alone prevents re-accumulation of fluid at 30 days

60%–80% of the time

D.

Systemic chemotherapy or hormonal therapy is the most

effective treatment

A 63-year-old male with advanced lung cancer is admitted to a palliative

care unit for pain management. Shortly after admission he develops

agitated delirium. He has no contraindications to the use of sedatives or

antipsychotics. His behavior is distressing to himself and his family.

Nonpharmacologic treatment has not been effective.

In addition to adjusting his pain medication, the most appropriate

treatment for this patient entering terminal delirium would be

A.

oral hydroxyzine (Vistaril)

B.

oral lorazepam (Ativan)

C.

oral haloperidol and diazepam (Valium)

D.

oral haloperidol and lorazepam

E.

intravenous morphine

A 63-year-old male with advanced lung cancer is admitted to a palliative

care unit for pain management. Shortly after admission he develops

agitated delirium. He has no contraindications to the use of sedatives or

antipsychotics. His behavior is distressing to himself and his family.

Nonpharmacologic treatment has not been effective.

In addition to adjusting his pain medication, the most appropriate

treatment for this patient entering terminal delirium would be

A.

oral hydroxyzine (Vistaril)

B.

oral lorazepam (Ativan)

C.

oral haloperidol and diazepam (Valium)

D.

oral haloperidol and lorazepam

E.

intravenous morphine

A 55-year-old female with metastatic breast cancer presents with her

husband, who reports that for the past 4 months she has had frequent

episodes of crying, a feeling of hopelessness, and a lack of interest in

activities that used to bring her joy. She is on palliative chemotherapy and

her life expectancy is greater than 3 months.

Which one of the following would be most appropriate at this point?

A.

No further evaluation because her symptoms are a normal response to her

terminal cancer diagnosis

B.

Administer a Patient Health Questionnaire–9 (PHQ-9) and a numerical rating scale

for pain

C.

Consider quetiapine (Seroquel) if insomnia is also present

D.

Offer hospitalization in a behavioral health unit

A 55-year-old female with metastatic breast cancer presents with her

husband, who reports that for the past 4 months she has had frequent

episodes of crying, a feeling of hopelessness, and a lack of interest in

activities that used to bring her joy. She is on palliative chemotherapy and

her life expectancy is greater than 3 months.

Which one of the following would be most appropriate at this point?

A.

No further evaluation because her symptoms are a normal response to her

terminal cancer diagnosis

B.

Administer a Patient Health Questionnaire–9 (PHQ-9) and a numerical

rating scale for pain

C.

Consider quetiapine (Seroquel) if insomnia is also present

D.

Offer hospitalization in a behavioral health unit

A patient with malignant melanoma and a 2-month history of mid-thoracic

back pain presents to the emergency department after a fall. She reports

significant progressive weakness over the past 3 days and is now unable to

climb stairs or to rise off the toilet seat unassisted.

The most important initial step for addressing this patient’s weakness would

be

A.

plain radiographs of the thoracic spine

B.

urgent MRI of the thoracic spine

C.

urgent MRI of the cervical, thoracic, and lumbar spine

D.

urgent CT myelography

A patient with malignant melanoma and a 2-month history of mid-thoracic

back pain presents to the emergency department after a fall. She reports

significant progressive weakness over the past 3 days and is now unable to

climb stairs or to rise off the toilet seat unassisted.

The most important initial step for addressing this patient’s weakness would

be

A.

plain radiographs of the thoracic spine

B.

urgent MRI of the thoracic spine

C.

urgent MRI of the cervical, thoracic, and lumbar spine

D.

urgent CT myelography

Which one of the following is true about a 53-year-old female with chronic

alcohol abuse who is hospitalized frequently with encephalopathy?

A.

A medical team may determine whether she is competent to make her

own health care decisions

B.

A judge may determine whether she is competent to make her own

health care decisions

C.

A social worker may determine whether she is capable of making her

own health care decisions

D.

Her health care proxy may automatically make financial decisions for

her when she is encephalopathic

Which one of the following is true about a 53-year-old female with chronic

alcohol abuse who is hospitalized frequently with encephalopathy?

A.

A medical team may determine whether she is competent to make her

own health care decisions

B.

A judge may determine whether she is competent to make her

own health care decisions

C.

A social worker may determine whether she is capable of making her

own health care decisions

D.

Her health care proxy may automatically make financial decisions for

her when she is encephalopathic

A 74-year-old male is hospitalized with heart failure and an ejection fraction

of 14%. He has shortness of breath at rest despite maximal medical

therapy. You include the drawing of an illness trajectory as part of your

palliative care discussion with the patient and his family.

Which one of the illness trajectories shown below would be most likely for

this patient?

A.

Sudden death

B.

Frailty

C.

Organ failure

D.

Cancer/terminal illness

A 74-year-old male is hospitalized with heart failure and an ejection fraction

of 14%. He has shortness of breath at rest despite maximal medical

therapy. You include the drawing of an illness trajectory as part of your

palliative care discussion with the patient and his family.

Which one of the illness trajectories shown below would be most likely for

this patient?

A.

Sudden death

B.

Frailty

C.

Organ failure

D.

Cancer/terminal illness

The 4 (now 5) Death Trajectories

The 4 (now 5) Death Trajectories

A 59-year-old patient with oxygen- and corticosteroid-dependent COPD is

admitted for severe respiratory distress. The pulmonologist recommends

intubation for mechanical ventilation and the patient’s family asks for your

opinion.

Which one of the following would be appropriate advice?

A.

If a ventilator is started it is unlikely to be needed long term

B.

A tracheostomy will typically be recommended only if intubation is

required for longer than 4 weeks

C.

If the family agrees to short-term intubation, a date should be set for

reevaluating the situation

D.

Withdrawal of mechanical respiratory support in a ventilator-

dependent patient would be physician-assisted suicide

E.

Weaning of ventilator support causes more distress than abrupt

withdrawal

A 59-year-old patient with oxygen- and corticosteroid-dependent COPD is

admitted for severe respiratory distress. The pulmonologist recommends

intubation for mechanical ventilation and the patient’s family asks for your

opinion.

Which one of the following would be appropriate advice?

A.

If a ventilator is started it is unlikely to be needed long term

B.

A tracheostomy will typically be recommended only if intubation is

required for longer than 4 weeks

C.

If the family agrees to short-term intubation, a date should be

set for reevaluating the situation

D.

Withdrawal of mechanical respiratory support in a ventilator-

dependent patient would be physician-assisted suicide

E.

Weaning of ventilator support causes more distress than abrupt

withdrawal

A 68-year-old male is hospitalized with multiple morbidities, including end-

stage heart, lung, and renal failure. His condition has been deteriorating

since he was admitted, despite optimal aggressive treatment. Family

members feel there is an impasse between the primary care physician who

suggests palliative treatment and the consulting specialists who encourage

aggressive interventions. They request input from the ethics committee but

the involved physicians resist.

Which one of the following is true in this situation?

A.

A family member may not request an ethics consult

B.

An ethics consult is more likely to help if it is obtained early in the

hospitalization

C.

Judges are barred from considering the opinions of the ethics committee in

deciding court cases

D.

The fact that an ethics investigation is conducted reflects poorly on the

involved physicians

A 68-year-old male is hospitalized with multiple morbidities, including end-

stage heart, lung, and renal failure. His condition has been deteriorating

since he was admitted, despite optimal aggressive treatment. Family

members feel there is an impasse between the primary care physician who

suggests palliative treatment and the consulting specialists who encourage

aggressive interventions. They request input from the ethics committee but

the involved physicians resist.

Which one of the following is true in this situation?

A.

A family member may not request an ethics consult

B.

An ethics consult is more likely to help if it is obtained early in the

hospitalization

C.

Judges are barred from considering the opinions of the ethics committee in

deciding court cases

D.

The fact that an ethics investigation is conducted reflects poorly on the

involved physicians

Many conversion charts suggest that a 12 µg/hour fentanyl transdermal

patch (Duragesic) is roughly equivalent to 30 mg of morphine in 24 hours.

Which one of the following would be the most appropriate fentanyl starting

dose for a person taking morphine sulfate (MS Contin), 30 mg every 8

hours, and immediate-release morphine, 7.5 mg two times daily?

A.

Half of a 12 µg/hour patch every 72 hours

B.

One 12 µg/hour patch every 72 hours

C.

One 25 µg/hour patch every 72 hours

D.

One 37.5 µg/hour patch every 72 hours

E.

One 50 µg/hour patch every 72 hours

Many conversion charts suggest that a 12 µg/hour fentanyl transdermal

patch (Duragesic) is roughly equivalent to 30 mg of morphine in 24 hours.

Which one of the following would be the most appropriate fentanyl starting

dose for a person taking morphine sulfate (MS Contin), 30 mg every 8

hours, and immediate-release morphine, 7.5 mg two times daily?

A.

Half of a 12 µg/hour patch every 72 hours

B.

One 12 µg/hour patch every 72 hours

C.

One 25 µg/hour patch every 72 hours

D.

One 37.5 µg/hour patch every 72 hours

E.

One 50 µg/hour patch every 72 hours

The total daily dose of oral opioid in this scenario is 105 milligrams

morphine equivalent (MME). 

An approximately equivalent fentanyl dose would be 40 µg/hour every 3

days. 

This should be decreased by 25% to 50% to allow for incomplete cross-

tolerance, which would be 21–32 µg/hour. 

Incomplete cross tolerance refers to the fact that in any individual, one

opioid might have a stronger effect than another. 

The patch should never be cut.

An 86-year-old female with a history of COPD and long-term tobacco use is treated for

recurrent pneumonia, which fails to improve despite multiple courses of antibiotics. CT

of the chest reveals multiple spiculated lesions throughout the lungs, as well as

partially visualized lesions in the dome of the right side of the liver suspicious for

metastatic cancer. She decides not to proceed with aggressive treatment and requests

your help in filling out her advance directive, which includes a discussion of CPR.

Which one of the following would be accurate advice when counseling this patient?

A.

Television shows depicting CPR have helped to promote widespread public

understanding of the procedure

B.

In the United States about 45% of all patients who receive CPR leave the hospital

alive

C.

In the United States about 20% of frail elderly who receive CPR leave the hospital

alive

D.

In the United States <1% of patients with advanced chronic disease who receive

CPR leave the hospital alive

An 86-year-old female with a history of COPD and long-term tobacco use is treated for

recurrent pneumonia, which fails to improve despite multiple courses of antibiotics. CT

of the chest reveals multiple spiculated lesions throughout the lungs, as well as

partially visualized lesions in the dome of the right side of the liver suspicious for

metastatic cancer. She decides not to proceed with aggressive treatment and requests

your help in filling out her advance directive, which includes a discussion of CPR.

Which one of the following would be accurate advice when counseling this patient?

A.

Television shows depicting CPR have helped to promote widespread public

understanding of the procedure

B.

In the United States about 45% of all patients who receive CPR leave the hospital

alive

C.

In the United States about 20% of frail elderly who receive CPR leave the hospital

alive

D.

In the United States <1% of patients with advanced chronic disease who

receive CPR leave the hospital alive

A 43-year-old male is treated for squamous cell carcinoma of the throat

using chemotherapy and radiation to his neck. Several days after radiation

treatment is started he begins to have pain with swallowing and develops

sensitivity and blistering of his oral cavity.

Which one of the following is true regarding this problem?

A.

A thorough dental examination is recommended before neck radiation

B.

All chemotherapeutic agents are associated with the same risk of

mucositis

C.

Prophylactic antifungal mouthwash should be used to decrease the risk

of mucositis

D.

Combination topical agents should not be used for pain relief of

mucositis

A 43-year-old male is treated for squamous cell carcinoma of the throat

using chemotherapy and radiation to his neck. Several days after radiation

treatment is started he begins to have pain with swallowing and develops

sensitivity and blistering of his oral cavity.

Which one of the following is true regarding this problem?

A.

A thorough dental examination is recommended before neck

radiation

B.

All chemotherapeutic agents are associated with the same risk of

mucositis

C.

Prophylactic antifungal mouthwash should be used to decrease the risk

of mucositis

D.

Combination topical agents should not be used for pain relief of

mucositis

A 45-year-old female with diffuse but treatable lymphoma asks you for a

referral to a palliative care specialist. You advise her that

A.

a palliative care specialist is appropriate at this time and you will

arrange it

B.

a palliative care specialist is appropriate only after radiation therapy is

completed

C.

a palliative care specialist is not appropriate because her life

expectancy may be greater than 6 months

D.

a palliative care specialist is not appropriate because there are still

treatment options available

A 45-year-old female with diffuse but treatable lymphoma asks you for a

referral to a palliative care specialist. You advise her that

A.

a palliative care specialist is appropriate at this time and you

will arrange it

B.

a palliative care specialist is appropriate only after radiation therapy is

completed

C.

a palliative care specialist is not appropriate because her life

expectancy may be greater than 6 months

D.

a palliative care specialist is not appropriate because there are still

treatment options available

A 94-year-old female nursing home resident has ischemic cardiomyopathy,

occasional angina, and an ejection fraction of 25%. She uses a wheelchair

but is able to pivot transfer. She is seen in the emergency department with

a new minimally displaced right hip fracture. The orthopedist has offered to

perform surgery to stabilize the fracture and reduce pain.

Which one of the following would be appropriate advice?

A.

The 1-year mortality rate for nonoperative management is similar to

that of surgery

B.

Early mobilization is appropriate if the hip is not repaired

C.

The risk of a heart attack automatically precludes hip surgery

D.

Surgery is the only option that will adequately address the pain

A 94-year-old female nursing home resident has ischemic cardiomyopathy,

occasional angina, and an ejection fraction of 25%. She uses a wheelchair

but is able to pivot transfer. She is seen in the emergency department with

a new minimally displaced right hip fracture. The orthopedist has offered to

perform surgery to stabilize the fracture and reduce pain.

Which one of the following would be appropriate advice?

A.

The 1-year mortality rate for nonoperative management is similar to

that of surgery

B.

Early mobilization is appropriate if the hip is not repaired

C.

The risk of a heart attack automatically precludes hip surgery

D.

Surgery is the only option that will adequately address the pain

For more than 2 months, a 52-year-old female with an unresectable

glioblastoma multiforme has been using extended-release morphine sulfate

(MS Contin), 60 mg orally every 8 hours, plus immediate-release morphine,

20 mg three times a day as needed for breakthrough pain. This regimen

provided good control of her pain until the last 2 weeks. During that time

she has had severe pain even with light touch, including moving the

blankets over her. Her pain has continued to increase despite escalating

doses of morphine.

Which one of the following is most likely to help her symptoms?

A.

Continuing to increase the morphine dosage until the pain is controlled

B.

Switching to continuous morphine subcutaneously at an equivalent dosage

C.

Adding diphenhydramine (Benadryl)

D.

Decreasing the morphine dosage and considering a change to a different opioid

For more than 2 months, a 52-year-old female with an unresectable

glioblastoma multiforme has been using extended-release morphine sulfate

(MS Contin), 60 mg orally every 8 hours, plus immediate-release morphine,

20 mg three times a day as needed for breakthrough pain. This regimen

provided good control of her pain until the last 2 weeks. During that time

she has had severe pain even with light touch, including moving the

blankets over her. Her pain has continued to increase despite escalating

doses of morphine.

Which one of the following is most likely to help her symptoms?

A.

Continuing to increase the morphine dosage until the pain is controlled

B.

Switching to continuous morphine subcutaneously at an equivalent dosage

C.

Adding diphenhydramine (Benadryl)

D.

Decreasing the morphine dosage and considering a change to a different

opioid

A 76-year-old male is scheduled for follow-up of his hypertension, diabetes

mellitus, and heart failure, after a recent hospitalization for exacerbation of

the heart failure. Before seeing the patient the staff uses the “Surprise

Question” approach to help them plan the discussion that will occur during

the visit.

Which one of the following accurately represents the Surprise Question?

A.

Would you be surprised if this patient fully recovered?

B.

Would you be surprised if this patient opted for aggressive treatment?

C.

Would you be surprised if this patient died in the next year?

D.

Would the patient be surprised if informed of a limited prognosis?

A 76-year-old male is scheduled for follow-up of his hypertension, diabetes

mellitus, and heart failure, after a recent hospitalization for exacerbation of

the heart failure. Before seeing the patient the staff uses the “Surprise

Question” approach to help them plan the discussion that will occur during

the visit.

Which one of the following accurately represents the Surprise Question?

A.

Would you be surprised if this patient fully recovered?

B.

Would you be surprised if this patient opted for aggressive treatment?

C.

Would you be surprised if this patient died in the next year?

D.

Would the patient be surprised if informed of a limited prognosis?

A 75-year-old female with type 1 diabetes presents with significant nausea.

A review of the patient’s medication list does not show any medications

likely to contribute to her nausea, and a CBC, comprehensive metabolic

panel, abdominal radiograph, and upper endoscopy are all normal. She

reports daily soft, large-volume bowel movements. Gastric emptying

testing shows delayed gastric emptying.

The medication most likely to help her nausea is

A.

haloperidol

B.

metoclopramide (Reglan)

C.

pregabalin (Lyrica)

D.

promethazine

E.

senna

A 75-year-old female with type 1 diabetes presents with significant nausea.

A review of the patient’s medication list does not show any medications

likely to contribute to her nausea, and a CBC, comprehensive metabolic

panel, abdominal radiograph, and upper endoscopy are all normal. She

reports daily soft, large-volume bowel movements. Gastric emptying

testing shows delayed gastric emptying.

The medication most likely to help her nausea is

A.

haloperidol

B.

metoclopramide (Reglan)

C.

pregabalin (Lyrica)

D.

promethazine

E.

senna

A hospitalized patient with alcohol use disorder requests to be sent home.

Which one of the following ethical decision-making concepts allows the

physician to discharge the patient despite the knowledge that he is likely to

relapse and begin drinking again?

A.

Autonomy

B.

Beneficence

C.

Nonmaleficence

D.

Justice

A hospitalized patient with alcohol use disorder requests to be sent home.

Which one of the following ethical decision-making concepts allows the

physician to discharge the patient despite the knowledge that he is likely to

relapse and begin drinking again?

A.

Autonomy

B.

Beneficence

C.

Nonmaleficence

D.

Justice

A 35-year-old female has started scheduled hydromorphone (Dilaudid)

tablets for pain associated with ovarian cancer. Which one of the following

side effects of opioids will not diminish with time and will likely require

active management?

A.

Constipation

B.

Drowsiness

C.

Foggy thinking

D.

Nausea

A 35-year-old female has started scheduled hydromorphone (Dilaudid)

tablets for pain associated with ovarian cancer. Which one of the following

side effects of opioids will not diminish with time and will likely require

active management?

A.

Constipation

B.

Drowsiness

C.

Foggy thinking

D.

Nausea

A hospice patient of yours has recently died and the family calls to ask if his

fentanyl transdermal patches (Duragesic) can be returned for disposal.

According to the Drug Enforcement Administration, which one of the

following is most appropriate for disposing of unused opioids?

A.

Fold the patches, sticky side in, and put them in the garbage

B.

Mix the patches with cat litter or coffee grounds and put them in the

garbage

C.

Put the patches in a drop box at a local police station, hospital, or

pharmacy

D.

Bring the patches back to the primary care clinic for disposal

A hospice patient of yours has recently died and the family calls to ask if his

fentanyl transdermal patches (Duragesic) can be returned for disposal.

According to the Drug Enforcement Administration, which one of the

following is most appropriate for disposing of unused opioids?

A.

Fold the patches, sticky side in, and put them in the garbage

B.

Mix the patches with cat litter or coffee grounds and put them in the

garbage

C.

Put the patches in a drop box at a local police station, hospital,

or pharmacy

D.

Bring the patches back to the primary care clinic for disposal

A 74-year-old female with advanced COPD has been hospitalized three

times in the past 6 months, each time requiring a period of ventilator

support in the intensive-care unit (ICU). Which one of the following

statements is true about ICU admissions for the frail elderly?

A.

Poor communication with family members often results in very elderly

patients in the ICU receiving less aggressive care than desired

B.

Frequent use of ICU admissions for the frail elderly have been shown

to decrease 6-month mortality

C.

Patients treated in a subacute-care unit rather than a traditional ICU

have been shown to have a decrease in mortality

D.

Frailty has not been shown to be an independent risk factor for ICU

mortality and 6-month mortality

A 74-year-old female with advanced COPD has been hospitalized three

times in the past 6 months, each time requiring a period of ventilator

support in the intensive-care unit (ICU). Which one of the following

statements is true about ICU admissions for the frail elderly?

A.

Poor communication with family members often results in very elderly

patients in the ICU receiving less aggressive care than desired

B.

Frequent use of ICU admissions for the frail elderly have been shown

to decrease 6-month mortality

C.

Patients treated in a subacute-care unit rather than a

traditional ICU have been shown to have a decrease in

mortality

D.

Frailty has not been shown to be an independent risk factor for ICU

mortality and 6-month mortality

A 52-year-old female with metastatic, end-stage ovarian cancer is admitted

to the hospital with nausea and bilious vomiting. Air-fluid levels are seen on

abdominal radiographs and CT shows a complete bowel obstruction. The

patient has a previous history of bowel obstruction but declined surgery.

Which one of the following would be most appropriate at this point?

A.

A nasogastric tube to relieve the pressure

B.

Octreotide (Sandostatin) subcutaneously

C.

Fentanyl (Duragesic), one 25 µg/hour transdermal patch every 72 hr

D.

A PET scan

A 52-year-old female with metastatic, end-stage ovarian cancer is admitted

to the hospital with nausea and bilious vomiting. Air-fluid levels are seen on

abdominal radiographs and CT shows a complete bowel obstruction. The

patient has a previous history of bowel obstruction but declined surgery.

Which one of the following would be most appropriate at this point?

A.

A nasogastric tube to relieve the pressure

B.

Octreotide (Sandostatin) subcutaneously

C.

Fentanyl (Duragesic), one 25 µg/hour transdermal patch every 72 hr

D.

A PET scan

A hospice patient tells you that he wants full-code status. Which one of the

following would be most appropriate for initiating counseling in this

situation?

A.

Inform him that full-code status is not permitted for hospice patients

B.

Describe the potential risks of CPR, such as broken ribs

C.

Ask him what he knows about the components of full resuscitation

D.

Ask to meet with his health care proxy

A hospice patient tells you that he wants full-code status. Which one of the

following would be most appropriate for initiating counseling in this

situation?

A.

Inform him that full-code status is not permitted for hospice patients

B.

Describe the potential risks of CPR, such as broken ribs

C.

Ask him what he knows about the components of full

resuscitation

D.

Ask to meet with his health care proxy

You see a 68-year-old male whose metastatic prostate cancer was

unsuccessfully treated with hormonal therapy. He presents with severe

suprapubic pain and is found to have a metastatic lesion in his symphysis

pubis. Opioid pain management helps but has not controlled his pain and

has caused heavy sedation and confusion. He lives at home with minimal

assistance.

The most appropriate first-line treatment option would be

A.

an increase in the oral opioid dosage

B.

daily oral NSAIDs

C.

intrathecal opioids

D.

anesthetic injections

E.

palliative radiation

You see a 68-year-old male whose metastatic prostate cancer was

unsuccessfully treated with hormonal therapy. He presents with severe

suprapubic pain and is found to have a metastatic lesion in his symphysis

pubis. Opioid pain management helps but has not controlled his pain and

has caused heavy sedation and confusion. He lives at home with minimal

assistance.

The most appropriate first-line treatment option would be

A.

an increase in the oral opioid dosage

B.

daily oral NSAIDs

C.

intrathecal opioids

D.

anesthetic injections

E.

palliative radiation

Which one of the following has been shown to prevent patients with late-

stage chronic illnesses from receiving unwanted and often futile

interventions?

A.

Having only a treatment-limiting advance directive

B.

Having only an identified surrogate decision maker available

C.

Having both a treatment-limiting advance directive and a surrogate

decision maker

D.

No method of communicating patient preferences

Which one of the following has been shown to prevent patients with late-

stage chronic illnesses from receiving unwanted and often futile

interventions?

A.

Having only a treatment-limiting advance directive

B.

Having only an identified surrogate decision maker available

C.

Having both a treatment-limiting advance directive and a

surrogate decision maker

D.

No method of communicating patient preferences

A 55-year-old male living in Colorado is diagnosed with colon cancer and

found to have bone metastases. After receiving radiation treatment he is

started on low-dose opioid medications. The medications help relieve his

symptoms but make him tired. He asks about the use of medical

marijuana.

Which one of the following statements is true regarding the use of medical

marijuana?

A.

It has been decriminalized in most states but its legality varies on a

city and county level

B.

It is closely regulated by the FDA

C.

There is robust data to support its utility as a first-line treatment of

cancer-related pain, nausea, and anxiety

D.

It contains many active metabolites that are present in varying

concentrations

A 55-year-old male living in Colorado is diagnosed with colon cancer and

found to have bone metastases. After receiving radiation treatment he is

started on low-dose opioid medications. The medications help relieve his

symptoms but make him tired. He asks about the use of medical

marijuana.

Which one of the following statements is true regarding the use of medical

marijuana?

A.

It has been decriminalized in most states but its legality varies on a

city and county level

B.

It is closely regulated by the FDA

C.

There is robust data to support its utility as a first-line treatment of

cancer-related pain, nausea, and anxiety

D.

I

t contains many active metabolites that are present in varying

concentrations

A 61-year-old female with a history of breast cancer diagnosed 7 years ago

has bone metastases and is brought to the emergency department (ED)

with a sudden onset of excruciating left hip pain that caused her to fall

while walking in her kitchen. She has no allergies, her vital signs are stable,

and her pain in the ED remains severe.

The most appropriate initial step in the ED would be

A.

plain radiographs of the left hip

B.

CT of the left hip

C.

oral opioids

D.

intravenous corticosteroids

E.

intravenous opioids

A 61-year-old female with a history of breast cancer diagnosed 7 years ago

has bone metastases and is brought to the emergency department (ED)

with a sudden onset of excruciating left hip pain that caused her to fall

while walking in her kitchen. She has no allergies, her vital signs are stable,

and her pain in the ED remains severe.

The most appropriate initial step in the ED would be

A.

plain radiographs of the left hip

B.

CT of the left hip

C.

oral opioids

D.

intravenous corticosteroids

E.

intravenous opioids

An 84-year-old female who is in a hospice facility with end-stage liver

disease is breathing heavily with her mouth open. She is moaning and

opens her eyes occasionally. She has not had anything to eat or drink in 2

days and her family asks about interventions for comfort.

Which one of the following would be appropriate to tell the family?

A.

Intravenous fluids improve patient comfort

B.

Cautiously titrated opioids do not hasten death

C.

Lorazepam (Ativan) should not be used routinely

D.

Supplemental oxygen should be used routinely

An 84-year-old female who is in a hospice facility with end-stage liver

disease is breathing heavily with her mouth open. She is moaning and

opens her eyes occasionally. She has not had anything to eat or drink in 2

days and her family asks about interventions for comfort.

Which one of the following would be appropriate to tell the family?

A.

Intravenous fluids improve patient comfort

B.

Cautiously titrated opioids do not hasten death

C.

Lorazepam (Ativan) should not be used routinely

D.

Supplemental oxygen should be used routinely

A 65-year-old female with breast cancer widely metastatic to bone presents

with confusion and decreased appetite. A laboratory workup reveals a

corrected serum calcium level of 13.9 mg/dL (N 8.6–10.0).

Which one of the following statements is true in this situation?

A.

Approximately 10% of patients with these findings will die within 30

days

B.

Depending on goals of care, not treating her hypercalcemia is an

option

C.

Furosemide (Lasix) is the drug of choice to treat this patient’s

hypercalcemia

D.

Bisphosphonate treatment may not be repeated for 30 days

A 65-year-old female with breast cancer widely metastatic to bone presents

with confusion and decreased appetite. A laboratory workup reveals a

corrected serum calcium level of 13.9 mg/dL (N 8.6–10.0).

Which one of the following statements is true in this situation?

A.

Approximately 10% of patients with these findings will die within 30

days

B.

Depending on goals of care, not treating her hypercalcemia is

an option

C.

Furosemide (Lasix) is the drug of choice to treat this patient’s

hypercalcemia

D.

Bisphosphonate treatment may not be repeated for 30 days

A 72-year-old farmer with stage IV adenocarcinoma of the lung wants to

assist his son on the farm and do what he can to participate in chores for

his remaining days, but he does not have enough energy to do so. He is

sleeping well and is not taking any opioids, benzodiazepines, or sleeping

medications.

Which one of the following is likely to be the most effective palliative

approach for this patient?

A.

Physical therapy to increase his endurance

B.

Methylphenidate to improve his energy

C.

Referral for behavioral health counseling

D.

Referral for a second oncologic opinion regarding additional

chemotherapy

A 72-year-old farmer with stage IV adenocarcinoma of the lung wants to

assist his son on the farm and do what he can to participate in chores for

his remaining days, but he does not have enough energy to do so. He is

sleeping well and is not taking any opioids, benzodiazepines, or sleeping

medications.

Which one of the following is likely to be the most effective palliative

approach for this patient?

A.

Physical therapy to increase his endurance

B.

Methylphenidate to improve his energy

C.

Referral for behavioral health counseling

D.

Referral for a second oncologic opinion regarding additional

chemotherapy

An 83-year-old female is receiving palliative chemotherapy for stage IV colon cancer

with bone metastases, which are managed with oral corticosteroids and opioid

medications. Her daughter calls to discuss her mother’s sleep disruption, which is

affecting the family’s ability to care for her. The problem seems to be due to frequent

jerky movements that awaken the patient and then her caregivers. On examination

she is awake and oriented but has occasional sudden jerking movements and twitches

of all four extremities.

Which one of the following would be the most appropriate initial management of the

sleep disruption?

A.

Review the patient’s medications and eliminate as many as possible

B.

Increase the nightly dose of the patient’s opioid by 10%–20%

C.

Prescribe an antiseizure medication such as levetiracetam (Keppra), 500 mg at

bedtime

D.

Recommend melatonin at bedtime

An 83-year-old female is receiving palliative chemotherapy for stage IV colon cancer

with bone metastases, which are managed with oral corticosteroids and opioid

medications. Her daughter calls to discuss her mother’s sleep disruption, which is

affecting the family’s ability to care for her. The problem seems to be due to frequent

jerky movements that awaken the patient and then her caregivers. On examination

she is awake and oriented but has occasional sudden jerking movements and twitches

of all four extremities.

Which one of the following would be the most appropriate initial management of the

sleep disruption?

A.

Review the patient’s medications and eliminate as many as possible

B.

Increase the nightly dose of the patient’s opioid by 10%–20%

C.

Prescribe an antiseizure medication such as levetiracetam (Keppra), 500 mg at

bedtime

D.

Recommend melatonin at bedtime

The Palliative Performance Scale (PPS) is a useful tool for clinicians,

patients, and families. Which one of the following is true about the PPS?

A.

It has been validated in large, multicenter trials

B.

It measures function in one domain to assess patient status

C.

Changes in the PPS score are useful to determine patient recertification

in hospice

D.

The PPS score has no correlation with longevity in outpatient cancer

patients

The Palliative Performance Scale (PPS) is a useful tool for clinicians,

patients, and families. Which one of the following is true about the PPS?

A.

It has been validated in large, multicenter trials

B.

It measures function in one domain to assess patient status

C.

Changes in the PPS score are useful to determine patient

recertification in hospice

D.

The PPS score has no correlation with longevity in outpatient cancer

patients

Denial can help patients cope with overwhelming news but it can also

hinder them from facing reality. A “Hope-Worry” statement is a tool that

caregivers can use to approach topics that patients want to avoid

discussing.

A “Hope-Worry” phrase would be appropriate when

A.

assessing what a patient understands about their illness

B.

a family member tells you that they think they should be doing more

for the patient

C.

a patient asks that their health care team talk only about positive

things

D.

a patient asks you to “hurry up this dying business”

Denial can help patients cope with overwhelming news but it can also

hinder them from facing reality. A “Hope-Worry” statement is a tool that

caregivers can use to approach topics that patients want to avoid

discussing.

A “Hope-Worry” phrase would be appropriate when

A.

assessing what a patient understands about their illness

B.

a family member tells you that they think they should be doing more

for the patient

C.

a patient asks that their health care team talk only about

positive things

D.

a patient asks you to “hurry up this dying business”

A 77-year-old female is found to have a new 3.5-cm pelvic mass. She has a long

history of multiple cancer diagnoses. Ten years ago she was treated for uterine cancer

and 3 years ago she was treated for colon cancer. Having gone through multiple

surgical procedures and rounds of chemotherapy in the past, she adamantly declines

further treatment. Her family history is positive for a brother who died at age 45 from

colon cancer and her mother’s death at an early age from endometrial cancer. The

patient has three living children. You want to encourage her to have genetic testing.

You advise the patient that genetic testing may

A.

allow her to participate in a research trial

B.

provide important information for her family

C.

help her pay for her ongoing care

D.

influence the monitoring process

A 77-year-old female is found to have a new 3.5-cm pelvic mass. She has a long

history of multiple cancer diagnoses. Ten years ago she was treated for uterine cancer

and 3 years ago she was treated for colon cancer. Having gone through multiple

surgical procedures and rounds of chemotherapy in the past, she adamantly declines

further treatment. Her family history is positive for a brother who died at age 45 from

colon cancer and her mother’s death at an early age from endometrial cancer. The

patient has three living children. You want to encourage her to have genetic testing.

You advise the patient that genetic testing may

A.

allow her to participate in a research trial

B.

provide important information for her family

C.

help her pay for her ongoing care

D.

influence the monitoring process

A terminally ill patient is not eating or drinking. The patient’s daughter is

concerned about hydration and asks about methods to address this.

You consider recommending parenteral hydration using hypodermoclysis

(HDC). Which one of the following statements about this method of

hydration is correct?

A.

Parenteral hydration is required when palliative care patients are

admitted to the hospital in order to justify their admission

B.

Nonmedical caregivers can be taught to safely administer HDC

C.

The same volume of fluid can be given by HDC as by intravenous

administration

D.

The preferred hydration solution for HDC is D5W

A terminally ill patient is not eating or drinking. The patient’s daughter is

concerned about hydration and asks about methods to address this.

You consider recommending parenteral hydration using hypodermoclysis

(HDC). Which one of the following statements about this method of

hydration is correct?

A.

Parenteral hydration is required when palliative care patients are

admitted to the hospital in order to justify their admission

B.

Nonmedical caregivers can be taught to safely administer HDC

C.

The same volume of fluid can be given by HDC as by intravenous

administration

D.

The preferred hydration solution for HDC is D5W

You and a family medicine resident working with you are asked to tell a 75-

year-old male that he has acute leukemia. To help the resident prepare for

this discussion you review the elements of the SPIKES mnemonic, which

stands for

A.

Situation, Perspective, Inhale, Knowledge, Educate, and

Strategy/Suggestions

B.

Smile, Perceive, Incline, Knowledge, Empathy, and Summary/Survey

C.

Setting, Perception, Invitation, Knowledge, Emotions, and

Strategy/Summary

D.

Sense, Practice, Inspire, Knowledge, Educate, and

Strategy/Suggestions

E.

Suggest, Personalize, Inspiration, Knowledge, Emphasize,

Survey/Smile

You and a family medicine resident working with you are asked to tell a 75-

year-old male that he has acute leukemia. To help the resident prepare for

this discussion you review the elements of the SPIKES mnemonic, which

stands for

A.

Situation, Perspective, Inhale, Knowledge, Educate, and

Strategy/Suggestions

B.

Smile, Perceive, Incline, Knowledge, Empathy, and Summary/Survey

C.

Setting, Perception, Invitation, Knowledge, Emotions, and

Strategy/Summary

D.

Sense, Practice, Inspire, Knowledge, Educate, and

Strategy/Suggestions

E.

Suggest, Personalize, Inspiration, Knowledge, Emphasize,

Survey/Smile

A 54-year-old male, who had not sought medical care for 20 years, was

recently diagnosed with advanced COPD. He has a 50-pack-year smoking

history, and stopped smoking 4 years ago. He reports that he now has

breathlessness even when walking around his home. He is found to have an

FEV1 <30% of predicted.

Which one of the following would be appropriate advice at this time?

A.

He is at risk for CO2 retention with excessive supplemental oxygen

B.

His disease is too advanced for him to benefit from pulmonary

rehabilitation

C.

His COPD at this point is untreatable

D.

He should avoid all opioids

A 54-year-old male, who had not sought medical care for 20 years, was

recently diagnosed with advanced COPD. He has a 50-pack-year smoking

history, and stopped smoking 4 years ago. He reports that he now has

breathlessness even when walking around his home. He is found to have an

FEV1 <30% of predicted.

Which one of the following would be appropriate advice at this time?

A.

He is at risk for CO2 retention with excessive supplemental

oxygen

B.

His disease is too advanced for him to benefit from pulmonary

rehabilitation

C.

His COPD at this point is untreatable

D.

He should avoid all opioids

A 46-year-old university professor has recently been diagnosed with early

amyotrophic lateral sclerosis (ALS). She and her partner ask about what to

expect.

Which one of the following would be appropriate counseling?

A.

A feeding tube is one option when the patient is not able to consume

sufficient nutrition

B.

A tracheostomy and ventilator may be offered but do not improve

longevity

C.

Pain is rare but when it is present it is difficult to treat

D.

New medications such as riluzole (Rilutek) and edaravone (Radicava)

improve symptoms but do not delay death

A 46-year-old university professor has recently been diagnosed with early

amyotrophic lateral sclerosis (ALS). She and her partner ask about what to

expect.

Which one of the following would be appropriate counseling?

A.

A feeding tube is one option when the patient is not able to

consume sufficient nutrition

B.

A tracheostomy and ventilator may be offered but do not improve

longevity

C.

Pain is rare but when it is present it is difficult to treat

D.

New medications such as riluzole (Rilutek) and edaravone (Radicava)

improve symptoms but do not delay death

A 48-year-old male with abdominal pain from pancreatic cancer is taking 8-

to 12-hour extended-release morphine, 30 mg orally every 8 hours, plus

immediate-release morphine, 10 mg orally every 4 hours as needed, taken

an average of three times a day. The patient has difficulty swallowing pills.

Which one of the following would be most appropriate at this time?

A.

Continue the extended-release and immediate-release morphine, as

they are working well together

B.

Continue the extended-release morphine for 72 hours after he starts

the fentanyl transdermal patch (Duragesic)

C.

Start the fentanyl transdermal patch and give one final extended-

release morphine dose at the same time

D.

Stop the extended-release morphine at night and begin the fentanyl

transdermal patch the next morning

A 48-year-old male with abdominal pain from pancreatic cancer is taking 8-

to 12-hour extended-release morphine, 30 mg orally every 8 hours, plus

immediate-release morphine, 10 mg orally every 4 hours as needed, taken

an average of three times a day. The patient has difficulty swallowing pills.

Which one of the following would be most appropriate at this time?

A.

Continue the extended-release and immediate-release morphine, as

they are working well together

B.

Continue the extended-release morphine for 72 hours after he starts

the fentanyl transdermal patch (Duragesic)

C.

Start the fentanyl transdermal patch and give one final

extended-release morphine dose at the same time

D.

Stop the extended-release morphine at night and begin the fentanyl

transdermal patch the next morning

A 55-year-old female who has been your patient for 30 years was recently diagnosed

with stage III breast cancer and presents to your office to discuss the treatment

options offered at her oncology appointment. She is with her husband, who is sitting

silently in the room while the patient discusses her fear and distrust of the options for

care that she was offered. The patient says that she wants to seek only natural and

alternative treatments for her cancer, including herbal and homeopathic treatments.

Which one of the following would be most appropriate at this visit?

A.

Ask the patient’s husband to step out of the room during the discussion to

enhance communication

B.

Tell the patient you agree with the treatment options provided and refer her back

to the oncologist

C.

Tell the patient her decision is not evidence based and you will not support it

D.

Assist the patient in understanding and evaluating the risks and benefits of all the

options

E.

Schedule a mental health assessment for your patient to determine her cognitive

status

A 55-year-old female who has been your patient for 30 years was recently diagnosed

with stage III breast cancer and presents to your office to discuss the treatment

options offered at her oncology appointment. She is with her husband, who is sitting

silently in the room while the patient discusses her fear and distrust of the options for

care that she was offered. The patient says that she wants to seek only natural and

alternative treatments for her cancer, including herbal and homeopathic treatments.

Which one of the following would be most appropriate at this visit?

A.

Ask the patient’s husband to step out of the room during the discussion to

enhance communication

B.

Tell the patient you agree with the treatment options provided and refer her back

to the oncologist

C.

Tell the patient her decision is not evidence based and you will not support it

D.

Assist the patient in understanding and evaluating the risks and benefits

of all the options

E.

Schedule a mental health assessment for your patient to determine her cognitive

status

38-year-old female with stage IV pancreatic cancer is on a morphine

intrathecal pump. Her pain is well managed but she has developed constant

itching.

Which one of the following is true?

A.

Itching is less common with intrathecal morphine than with oral or

parenteral morphine

B.

Itching from morphine is a sign of allergy and increases her risk for

anaphylaxis

C.

Itching should prompt switching from morphine to a non-opioid pain

medication

D.

Ondansetron (Zofran) has been shown to have some effectiveness for

managing opioid-induced pruritus

38-year-old female with stage IV pancreatic cancer is on a morphine

intrathecal pump. Her pain is well managed but she has developed constant

itching.

Which one of the following is true?

A.

Itching is less common with intrathecal morphine than with oral or

parenteral morphine

B.

Itching from morphine is a sign of allergy and increases her risk for

anaphylaxis

C.

Itching should prompt switching from morphine to a non-opioid pain

medication

D.

Ondansetron (Zofran) has been shown to have some

effectiveness for managing opioid-induced pruritus

A 74-year-old hospice patient with prostate cancer and metastatic bone disease has

been taking morphine, 5 mg orally every 4 hours as needed for pain, averaging six

doses a day. He reports that his pain level is 5–7 on a scale of 10, which he feels is

tolerable. However, he has moments of breakthrough pain and it is difficult for him to

take the medicine so frequently.

Which one of the following would be most appropriate at this point?

A.

Continue the current dosage

B.

Increase the morphine to every 3 hours as needed

C.

Add oxycodone (Roxicodone), 5 mg orally every 4 hours as needed

D.

Add extended-release morphine sulfate (MS Contin), 15 mg orally every 12 hours

E.

Add fentanyl (Duragesic), 12 µg/hour via transdermal patch daily

A 74-year-old hospice patient with prostate cancer and metastatic bone disease has

been taking morphine, 5 mg orally every 4 hours as needed for pain, averaging six

doses a day. He reports that his pain level is 5–7 on a scale of 10, which he feels is

tolerable. However, he has moments of breakthrough pain and it is difficult for him to

take the medicine so frequently.

Which one of the following would be most appropriate at this point?

A.

Continue the current dosage

B.

Increase the morphine to every 3 hours as needed

C.

Add oxycodone (Roxicodone), 5 mg orally every 4 hours as needed

D.

Add extended-release morphine sulfate (MS Contin), 15 mg orally every

12 hours

E.

Add fentanyl (Duragesic), 12 µg/hour via transdermal patch daily

A 58-year-old male with a history of prostate cancer with vertebral metastases

presents to the emergency department with uncontrolled back pain that he rates as 10

on a scale of 10. His home pain regimen includes extended-release morphine sulfate

(MS Contin), 30 mg every 8 hours. For breakthrough pain he takes immediate-release

morphine sulfate, 15 mg every 4 hours as needed. He has taken six doses of short-

acting medication in the last 24 hours, along with his scheduled pain medications. He is

given a single dose of hydromorphone (Dilaudid), 1 mg intravenously, and reassessed.

His pain score has decreased only to 9 out of 10 and he is still uncomfortable and

writhing in pain.

Which one of the following would be the most appropriate next step in managing this

patient’s pain?

A.

Morphine, 15 mg orally, and reassessment in 30 minutes

B.

Acetaminophen, 1000 mg intravenously in a single dose

C.

Hydromorphone, 0.5 mg intravenously, and reassessment in 30 minutes

D.

Hydromorphone, 2.0 mg intravenously, and reassessment in 10 minutes

A 58-year-old male with a history of prostate cancer with vertebral metastases

presents to the emergency department with uncontrolled back pain that he rates as 10

on a scale of 10. His home pain regimen includes extended-release morphine sulfate

(MS Contin), 30 mg every 8 hours. For breakthrough pain he takes immediate-release

morphine sulfate, 15 mg every 4 hours as needed. He has taken six doses of short-

acting medication in the last 24 hours, along with his scheduled pain medications. He is

given a single dose of hydromorphone (Dilaudid), 1 mg intravenously, and reassessed.

His pain score has decreased only to 9 out of 10 and he is still uncomfortable and

writhing in pain.

Which one of the following would be the most appropriate next step in managing this

patient’s pain?

A.

Morphine, 15 mg orally, and reassessment in 30 minutes

B.

Acetaminophen, 1000 mg intravenously in a single dose

C.

Hydromorphone, 0.5 mg intravenously, and reassessment in 30 minutes

D.

Hydromorphone, 2.0 mg intravenously, and reassessment in 10 minutes

A 51-year-old female has long-standing poorly controlled diabetes mellitus, atrial

fibrillation, and idiopathic cardiomyopathy with an ejection fraction of <15%. She has

had multiple hospitalizations and has spent 4 of the last 6 months in a skilled nursing

facility. She has developed severe cardiorenal syndrome and is not a transplant

candidate. You have been asked to see her for a conversation about goals of care.

Your discussion should include all of the following EXCEPT

A.

her understanding of her illness

B.

her past health experiences

C.

her worries and hopes

D.

her plans for the future

E.

why she keeps getting sick

A 51-year-old female has long-standing poorly controlled diabetes mellitus, atrial

fibrillation, and idiopathic cardiomyopathy with an ejection fraction of <15%. She has

had multiple hospitalizations and has spent 4 of the last 6 months in a skilled nursing

facility. She has developed severe cardiorenal syndrome and is not a transplant

candidate. You have been asked to see her for a conversation about goals of care.

Your discussion should include all of the following EXCEPT

A.

her understanding of her illness

B.

her past health experiences

C.

her worries and hopes

D.

her plans for the future

E.

why she keeps getting sick

A 48-year-old male with a 10-year history of chronic kidney disease now

has an estimated glomerular filtration rate less than 10 mL/min/1.73 m2

and has been advised to start hemodialysis. Which one of the following

would be appropriate advice regarding hemodialysis?

A.

If he starts dialysis he is likely to experience pruritus, hypotension,

muscle cramping, and fatigue

B.

If he starts dialysis he will be able to continue taking his scheduled

morphine

C.

If he does not start dialysis he will probably die within 1–2 months

D.

A trial of hemodialysis is low risk and will not affect his remaining renal

function

A 48-year-old male with a 10-year history of chronic kidney disease now

has an estimated glomerular filtration rate less than 10 mL/min/1.73 m2

and has been advised to start hemodialysis. Which one of the following

would be appropriate advice regarding hemodialysis?

A.

If he starts dialysis he is likely to experience pruritus,

hypotension, muscle cramping, and fatigue

B.

If he starts dialysis he will be able to continue taking his scheduled

morphine

C.

If he does not start dialysis he will probably die within 1–2 months

D.

A trial of hemodialysis is low risk and will not affect his remaining renal

function

Which one of the following is a side effect of high-dose, frequent marijuana

use?

A.

Anorexia

B.

Excessive salivation

C.

Flashback

D.

Hypertension

E.

Vomiting

Which one of the following is a side effect of high-dose, frequent marijuana

use?

A.

Anorexia

B.

Excessive salivation

C.

Flashback

D.

Hypertension

E.

Vomiting

A 10-year-old male with glioblastoma multiforme is brought to your local

emergency department (ED) by ambulance after he had a prolonged

seizure while at school. Despite the efforts of the ED team, the child dies.

You are his primary physician and are called to tell the parents, who have

been in the ED waiting area for over an hour. You begin by saying, “I have

heavy news… Noah has died.” The family becomes quite distraught.

Which one of the following would be the best thing to say at this point?

A.

God wanted another flower in his garden

B.

I understand what you are going through

C.

You are still young and you can have another child

D.

I’m so sorry to have to tell you this

A 10-year-old male with glioblastoma multiforme is brought to your local

emergency department (ED) by ambulance after he had a prolonged

seizure while at school. Despite the efforts of the ED team, the child dies.

You are his primary physician and are called to tell the parents, who have

been in the ED waiting area for over an hour. You begin by saying, “I have

heavy news… Noah has died.” The family becomes quite distraught.

Which one of the following would be the best thing to say at this point?

A.

God wanted another flower in his garden

B.

I understand what you are going through

C.

You are still young and you can have another child

D.

I’m so sorry to have to tell you this

A 62-year-old female presents to your clinic with right hip pain and a

radiograph is reported to show a “suspicious sclerotic lesion with a thin

cortex at high risk for hip fracture.” MRI of the hip shows extensive

metastatic disease involving the entire femoral neck. A palpable, firm, 4-cm

lesion is identified in her right breast. You are able to control her pain with

medication.

The most urgent need at this time is for

A.

chemotherapy by the oncologist

B.

radiation to the lesion by the oncologist

C.

bronchoscopy by the pulmonologist

D.

hip stabilization by the orthopedic surgeon

E.

review with an ethics committee

A 62-year-old female presents to your clinic with right hip pain and a

radiograph is reported to show a “suspicious sclerotic lesion with a thin

cortex at high risk for hip fracture.” MRI of the hip shows extensive

metastatic disease involving the entire femoral neck. A palpable, firm, 4-cm

lesion is identified in her right breast. You are able to control her pain with

medication.

The most urgent need at this time is for

A.

chemotherapy by the oncologist

B.

radiation to the lesion by the oncologist

C.

bronchoscopy by the pulmonologist

D.

hip stabilization by the orthopedic surgeon

E.

review with an ethics committee

A 65-year-old male is experiencing complications from diabetes mellitus and

hypertension. During a brief hospitalization for complications of his diabetes, you talk

with the patient and his family about his changing health condition and his wishes for

the future.

Which one of the following would be the most appropriate initial question to ask this

patient?

A.

If your heart was beating but your brain was dead, would you want to be kept

alive?

B.

Would you want to be placed on a ventilator if it is indicated?

C.

If your heart stops, would you like us to try to revive you with CPR?

D.

What do you know about your current health issues?

A 65-year-old male is experiencing complications from diabetes mellitus and

hypertension. During a brief hospitalization for complications of his diabetes, you talk

with the patient and his family about his changing health condition and his wishes for

the future.

Which one of the following would be the most appropriate initial question to ask this

patient?

A.

If your heart was beating but your brain was dead, would you want to be kept

alive?

B.

Would you want to be placed on a ventilator if it is indicated?

C.

If your heart stops, would you like us to try to revive you with CPR?

D.

What do you know about your current health issues?

A 70-year-old female who is in hospice care with multiple myeloma and diffuse bone

pain has good relief most of the day from a fentanyl transdermal patch (Duragesic), 50

µg/hour every 72 hours, which is roughly 125 milligrams morphine equivalent (MME)

daily. However, she has breakthrough pain most mornings while showering and

dressing.

Which one of the following would be most appropriate at this time?

A.

Essential oils rubbed onto the lower back at night

B.

Acetaminophen, every 4 hours as needed for breakthrough pain

C.

Morphine, 2.5 mg orally every 4 hours as needed for breakthrough pain

D.

Morphine, 15 mg orally every 4 hours as needed for breakthrough pain

A 70-year-old female who is in hospice care with multiple myeloma and diffuse bone

pain has good relief most of the day from a fentanyl transdermal patch (Duragesic), 50

µg/hour every 72 hours, which is roughly 125 milligrams morphine equivalent (MME)

daily. However, she has breakthrough pain most mornings while showering and

dressing.

Which one of the following would be most appropriate at this time?

A.

Essential oils rubbed onto the lower back at night

B.

Acetaminophen, every 4 hours as needed for breakthrough pain

C.

Morphine, 2.5 mg orally every 4 hours as needed for breakthrough pain

D.

Morphine, 15 mg orally every 4 hours as needed for breakthrough pain

Breakthrough pain is common even for patients taking long-acting opioid medication and may be treated with 10%–15% of the daily

opioid dose, which in this case would be 12–18 mg of morphine. Recent studies suggest that the ratio of transdermal fentanyl in

µg/hour to daily oral milligrams morphine equivalent (MME) is 1:2.5. Essential oils may provide some benefits but the research on

their efficacy and side-effect profile is limited. Acetaminophen would not be an adequate choice for a patient on high-dose opioid

therapy.

A determination is made that a 93-year-old female with severe osteoarthritis of her

knees is not a surgical candidate due to advanced cerebrovascular and cardiac disease.

She experiences severe knee pain when she tries to walk more than a few steps.

Acetaminophen has not been effective and she takes nabumetone, 500 mg daily, with

close monitoring of her renal function.

The most appropriate next step for her pain management would be

A.

elastic knee braces

B.

a progressive physical therapy walking program

C.

oral glucosamine/chondroitin

D.

low-dose tramadol (Ultram) therapy

E.

platelet-rich plasma injections of the knees

A determination is made that a 93-year-old female with severe osteoarthritis of her

knees is not a surgical candidate due to advanced cerebrovascular and cardiac disease.

She experiences severe knee pain when she tries to walk more than a few steps.

Acetaminophen has not been effective and she takes nabumetone, 500 mg daily, with

close monitoring of her renal function.

The most appropriate next step for her pain management would be

A.

elastic knee braces

B.

a progressive physical therapy walking program

C.

oral glucosamine/chondroitin

D.

low-dose tramadol (Ultram) therapy

E.

platelet-rich plasma injections of the knees

A 67-year-old male with metastatic malignant melanoma has questions

about hospice. Which one of the following statements about hospice is true?

A.

A person receiving hospice care is not permitted to return to the

hospital

B.

If a patient is still alive after 6 months on hospice, that person must

leave hospice care

C.

A multidisciplinary hospice team meets to discuss patient care every 2

weeks

D.

Hospice has been shown to increase the “widow effect”

A 67-year-old male with metastatic malignant melanoma has questions

about hospice. Which one of the following statements about hospice is true?

A.

A person receiving hospice care is not permitted to return to the

hospital

B.

If a patient is still alive after 6 months on hospice, that person must

leave hospice care

C.

A multidisciplinary hospice team meets to discuss patient care

every 2 weeks

D.

Hospice has been shown to increase the “widow effect”